Doctor penalized for poor record keeping

A Pennsylvania doctor was recently assessed a civil penalty of $2,000 and ordered to enroll in a remedial education program due to purported problems with the keeping of medical records. The doctor apparently did not note in the records changes in a patient’s medical condition, nor did the doctor report the symptoms reported when prescribing a particular patient a controlled substance. It seems the doctor also failed to record details in prescribing the controlled substance.

The danger in errors in recordkeeping is that future medical providers are often in the dark as to what medications the patient is already taking. Combinations of certain medications can often result in adverse consequences and even overdoses for the patient.

The doctor in question is accused of not keeping accurate or legible records that would reflect the course of treatment or the condition of the patient. We’ve spoken in the past about how poor recordkeeping and inadequate communication is often one of the primary causes of medical malpractice.

Though the civil penalties for the doctor may be a great inconvenience, it is hoped that the doctor will learn his lesson. Too often, such mistakes are not discovered until tragic consequences occurred. What is particular disturbing when severe injuries or deaths occur under these circumstances is that these happenings could easily have been avoided.

When civil penalties do not prevent the behavior from occurring, medical malpractice lawsuits brought by experienced attorneys may be brought. These suits provide greater incentives for medical providers to keep proper records and create safety procedures so that medical information is communicated accurately.

Source: Times Leader, “Discipline handed down,” by Andrew M. Seder, Dec. 5, 2012